Table 1 Citrate accumulation and alternative diagnoses: summary table
From: Complications of regional citrate anticoagulation: accumulation or overload?
Citrate accumulation | Citrate net overload | Insufficient trisodium citrate delivery | |
|---|---|---|---|
Mechanism | Incomplete citrate metabolism: persistence of circulating citrate–calcium complexes in the blood | Excess citrate administration relative to buffer requirements | Insufficient alkalotic load administered to the patient to adequately buffer acute kidney injury-associated acidosis |
Diagnosis | |||
Acid-base | Metabolic acidosis | Metabolic alkalosis | Metabolic acidosis |
Catot/Cai ratio | Increased (>2.5) | Normal (< 2.5) | Normal (< 2.5) |
Other | Increased need for calcium substitution Trend for a decreased ionized calcium level | None | None |
Appreciation | Potentially lethal (via severe hypocalcemia) | Benign and easy to fix | Benign and easy to fix |
Incidence | Rare | Common | Rare |
Management | Decrease blood flow or increase dialysate flow rate (if mild) Consider alternative anticoagulation strategy | Decrease blood flow or increase dialysate flow rate | Increase blood flow or decrease dialysate flow rate |